Radiation Effects on the Temporal Bone

  • Christopher D. Frisch
  • Beth M. Beadle
  • Paul W. GidleyEmail author


Radiation therapy is a common technique used in the multimodality treatment of head and neck cancers. Radiation causes cell death by a variety of mechanisms, and it may cause damage to both the target cancer cells and adjacent normal tissues. Radiation delivered directly to the temporal bone, or to neighboring subsites, can result in damage ranging from inflammation and infection to osteoradionecrosis or secondary malignancy. The delivered radiation dose appears to be the primary factor driving the development of these side effects. The pathophysiology of radiotherapy and its dose-response relationship will be discussed for the development of different complications. Treatment of these clinical problems will then be outlined.


Radiation Temporal bone Radiation effects Osteoradionecrosis Radiation-associated malignancy Carotid rupture Cochlear implant Chronic otitis media Conductive hearing loss 


  1. 1.
    Popovtzer A, Eisbruch A. Radiotherapy for head and neck cancer. In: Flint PW, Haughey BH, Lund VJ, Niparko JK, Robbins KT, Thomas JR, et al., editors. Cummings otolaryngology, head and neck surgery. 2. 6th ed. Philadelphia: Elsevier; 2015. p. 1088–109.Google Scholar
  2. 2.
    Schuknecht HF, Karmody CS. Radionecrosis of the temporal bone. Laryngoscope. 1966;76(8):1416–28.PubMedCrossRefGoogle Scholar
  3. 3.
    Lustig LR, Jackler RK, Lanser MJ. Radiation-induced tumors of the temporal bone. Am J Otol. 1997;18(2):230–5.PubMedGoogle Scholar
  4. 4.
    Ondrey FG, Greig JR, Herscher L. Radiation dose to otologic structures during head and neck cancer radiation therapy. Laryngoscope. 2000;110(2 Pt 1):217–21.PubMedCrossRefGoogle Scholar
  5. 5.
    Leonetti JP, Marzo SJ, Zender CA, Porter RG, Melian E. Temporal bone osteoradionecrosis after surgery and radiotherapy for malignant parotid tumors. Otol Neurotol. 2010;31(4):656–9.PubMedGoogle Scholar
  6. 6.
    Johannesen TB, Rasmussen K, Winther FØ, Halvorsen U, Lote K. Late radiation effects on hearing, vestibular function, and taste in brain tumor patients. Int J Radiat Oncol Biol Phys. 2002;53(1):86–90.PubMedCrossRefGoogle Scholar
  7. 7.
    Lambert EM, Gunn GB, Gidley PW. Effects of radiation on the temporal bone in patients with head and neck cancer. Head Neck. 2016;38(9):1428–35.PubMedPubMedCentralCrossRefGoogle Scholar
  8. 8.
    Jereczek-Fossa BA, Rondi E, Zarowski A, D’Onofrio A, Alterio D, Ciocca M, et al. Prospective study on the dose distribution to the acoustic structures during postoperative 3D conformal radiotherapy for parotid tumors: dosimetric and audiometric aspects. Strahlenther Onkol. 2011;187(6):350–6.PubMedCrossRefGoogle Scholar
  9. 9.
    Guadagnolo BA, Liu CC, Cormier JN, Du XL. Evaluation of trends in the use of intensity-modulated radiotherapy for head and neck cancer from 2000 through 2005. Cancer. 2010;116(14):3505–12.PubMedCrossRefGoogle Scholar
  10. 10.
    Miah AB, Gulliford SL, Clark CH, Bhide SA, Zaidi SH, Newbold KL, et al. Dose–response analysis of parotid gland function: what is the best measure of xerostomia? Radiother Oncol. 2013;106(3):341–5.PubMedCrossRefGoogle Scholar
  11. 11.
    Beadle BM, Liao KP, Elting LS, Buchholz TA, Ang KK, Garden AS, et al. Improved survival using intensity-modulated radiation therapy in head and neck cancers: a SEER-Medicare analysis. Cancer. 2014;120(5):702–10.PubMedCrossRefGoogle Scholar
  12. 12.
    Beetz I, Steenbakkers RJ, Chouvalova O, Leemans CR, Doornaert P, van der Laan BF, et al. The QUANTEC criteria for parotid gland dose and their efficacy to prevent moderate to severe patient-rated xerostomia. Acta Oncol. 2014;53(5):597–604.PubMedCrossRefGoogle Scholar
  13. 13.
    The National Association for Proton Therapy. Patient resources [cited 2016, 12/1/2016]. Available from:
  14. 14.
    Pasha R, Golub JS. Otolaryngology-head and neck surgery: clinical reference guide. San Diego, CA: Plural Publishing; 2013.Google Scholar
  15. 15.
    Trotti A. Toxicity in head and neck cancer: a review of trends and issues. Int J Radiat Oncol Biol Phys. 2000;47(1):1–12.PubMedCrossRefGoogle Scholar
  16. 16.
    Black JO. Xeroderma pigmentosum. Head Neck Pathol. 2016;10(2):139–44.PubMedPubMedCentralCrossRefGoogle Scholar
  17. 17.
    Porock D, Nikoletti S, Cameron F. The relationship between factors that impair wound healing and the severity of acute radiation skin and mucosal toxicities in head and neck cancer. Cancer Nurs. 2004;27(1):71–8.PubMedCrossRefGoogle Scholar
  18. 18.
    Zenda S, Ota Y, Tachibana H, Ogawa H, Ishii S, Hashiguchi C, et al. A prospective picture collection study for a grading atlas of radiation dermatitis for clinical trials in head-and-neck cancer patients. J Radiat Res. 2016;57(3):301–6.PubMedPubMedCentralCrossRefGoogle Scholar
  19. 19.
    Elwany S. Delayed ultrastructural radiation induced changes in the human mesotympanic middle ear mucosa. J Laryngol Otol. 1985;99(4):343–53.PubMedCrossRefGoogle Scholar
  20. 20.
    Carlson ML, Jacob JT, Pollock BE, Neff BA, Tombers NM, Driscoll CL, et al. Long-term hearing outcomes following stereotactic radiosurgery for vestibular schwannoma: patterns of hearing loss and variables influencing audiometric decline. J Neurosurg. 2013;118(3):579–87.PubMedCrossRefGoogle Scholar
  21. 21.
    Williams H, Davies A. The effect of X-rays on bone: a pictorial review. Eur Radiol. 2006;16(3):619–33.PubMedCrossRefGoogle Scholar
  22. 22.
    Cao X, Wu X, Frassica D, Yu B, Pang L, Xian L, et al. Irradiation induces bone injury by damaging bone marrow microenvironment for stem cells. Proc Natl Acad Sci U S A. 2011;108(4):1609–14.PubMedPubMedCentralCrossRefGoogle Scholar
  23. 23.
    Xie X, Qiu W, Yuan W, Wang Z. Experimental study of radiation effect on the mandibular microvasculature of the guinea pig. Chin J Dent Res. 1998;1(2):46–51.PubMedGoogle Scholar
  24. 24.
    Milliat F, François A, Isoir M, Deutsch E, Tamarat R, Tarlet G, et al. Influence of endothelial cells on vascular smooth muscle cells phenotype after irradiation: implication in radiation-induced vascular damages. Am J Pathol. 2006;169(4):1484–95.PubMedPubMedCentralCrossRefGoogle Scholar
  25. 25.
    Bray FN, Simmons BJ, Wolfson AH, Nouri K. Acute and chronic cutaneous reactions to ionizing radiation therapy. Dermatol Ther. 2016;6(2):185–206.CrossRefGoogle Scholar
  26. 26.
    Hemati S, Asnaashari O, Sarvizadeh M, Motlagh BN, Akbari M, Tajvidi M, et al. Topical silver sulfadiazine for the prevention of acute dermatitis during irradiation for breast cancer. Support Care Cancer. 2012;20(8):1613–8.PubMedCrossRefGoogle Scholar
  27. 27.
    Jung TT, Park YM, Panossian D, Weeks D, Miller SK, Sandefur J, et al. Effect of the radioprotector WR2721 on irradiation-induced injury to ciliated cells of eustachian tube. Ann Otol Rhinol Laryngol. 1992;101(5):395–402.PubMedCrossRefGoogle Scholar
  28. 28.
    Walker GV, Ahmed S, Allen P, Gidley PW, Woo SY, DeMonte F, et al. Radiation-induced middle ear and mastoid opacification in skull base tumors treated with radiotherapy. Int J Radiat Oncol Biol Phys. 2011;81(5):e819–23.PubMedCrossRefGoogle Scholar
  29. 29.
    Takasaki K, Takahashi H, Miyamoto I, Yoshida H, Yamamoto-Fukuda T, Enatsu K, et al. Measurement of angle and length of the eustachian tube on computed tomography using the multiplanar reconstruction technique. Laryngoscope. 2007;117(7):1251–4.PubMedCrossRefGoogle Scholar
  30. 30.
    Pulec JL, Simonton KM. Abnormal patency of the eustachian tube: report on 41 cases. Laryngoscope. 1964;74(2):267–71.PubMedCrossRefGoogle Scholar
  31. 31.
    Wang SZ, Li J, Miyamoto CT, Chen F, Zhou LF, Zhang HY, et al. A study of middle ear function in the treatment of nasopharyngeal carcinoma with IMRT technique. Radiother Oncol. 2009;93(3):530–3.PubMedCrossRefGoogle Scholar
  32. 32.
    Yamamoto K, Yaguchi Y, Kojima H. Clinical analysis of secondary acquired cholesteatoma. Am J Otolaryngol. 2014;35(5):589–93.PubMedCrossRefGoogle Scholar
  33. 33.
    Xu YD, Ou YK, Zheng YQ, Chen Y, Ji SF. The treatment for postirradiation otitis media with effusion: a study of three methods. Laryngoscope. 2008;118(11):2040–3.PubMedCrossRefGoogle Scholar
  34. 34.
    Morton RP, Woollons AC, McIvor NP. Nasopharyngeal carcinoma and middle ear effusion: natural history and the effect of ventilation tubes. Clin Otolaryngol Allied Sci. 1994;19(6):529–31.PubMedCrossRefGoogle Scholar
  35. 35.
    Soo G, Tong MC, Tsang WS, Wong TK, To KF, Lueng SF, et al. The BAHA hearing system for hearing-impaired postirradiated nasopharyngeal cancer patients: a new indication. Otol Neurotol. 2009;30(4):496–501.PubMedCrossRefGoogle Scholar
  36. 36.
    Nader ME, Beadle BM, Roberts DB, Gidley PW. Outcomes and complications of osseointegrated hearing aids in irradiated temporal bones. Laryngoscope. 2015;126(5):1187–92.PubMedCrossRefGoogle Scholar
  37. 37.
    Hsu YC, Su CY. Tympanoplasty for chronic otitis media in post-irradiated nasopharyngeal carcinoma patients. Ann Otol Rhinol Laryngol. 2006;115(5):330–3.PubMedCrossRefGoogle Scholar
  38. 38.
    Bennett M, Kaylie D, Warren F, Jackson CG. Chronic ear surgery in irradiated temporal bones. Laryngoscope. 2007;117(7):1240–4.PubMedCrossRefGoogle Scholar
  39. 39.
    Oghalai JS, Driscoll CL. Temporal bone surgery for infectious disease. Atlas of neurotologic and lateral skull base surgery. Berlin: Springer; 2016. p. 193–220.Google Scholar
  40. 40.
    Yilmaz YF, Aytas FI, Akdogan O, Sari K, Savas ZG, Titiz A, et al. Sensorineural hearing loss after radiotherapy for head and neck tumors: a prospective study of the effect of radiation. Otol Neurotol. 2008;29(4):461–3.PubMedCrossRefGoogle Scholar
  41. 41.
    Chen WC, Jackson A, Budnick AS, Pfister DG, Kraus DH, Hunt MA, et al. Sensorineural hearing loss in combined modality treatment of nasopharyngeal carcinoma. Cancer. 2006;106(4):820–9.PubMedCrossRefGoogle Scholar
  42. 42.
    Nitta Y, Araki N, Nitta K, Harada T, Ishizaki F, Ando J. Effects of high linear energy transfer radiation on the cochlea of C3H/He mouse during postnatal developmental course. J Radiat Res. 2005;46(1):75–81.PubMedCrossRefGoogle Scholar
  43. 43.
    Hoistad DL, Ondrey FG, Mutlu C, Schachern PA, Paparella MM, Adams GL. Histopathology of human temporal bone after cis-platinum, radiation, or both. Otolaryngol Head Neck Surg. 1998;118(6):825–32.PubMedCrossRefGoogle Scholar
  44. 44.
    Honoré HB, Bentzen SM, Møller K, Grau C. Sensori-neural hearing loss after radiotherapy for nasopharyngeal carcinoma: individualized risk estimation. Radiother Oncol. 2002;65(1):9–16.PubMedCrossRefGoogle Scholar
  45. 45.
    Ho WK, Wei WI, Kwong DL, Sham JS, Tai PT, Yuen AP, et al. Long-term sensorineural hearing deficit following radiotherapy in patients suffering from nasopharyngeal carcinoma: a prospective study. Head Neck. 1999;21(6):547–53.PubMedCrossRefGoogle Scholar
  46. 46.
    Kwong DL, Wei WI, Sham JS, Ho WK, Yuen PW, Chua DT, et al. Sensorineural hearing loss in patients treated for nasopharyngeal carcinoma: a prospective study of the effect of radiation and cisplatin treatment. Int J Radiat Oncol Biol Phys. 1996;36(2):281–9.PubMedCrossRefGoogle Scholar
  47. 47.
    Hitchcock YJ, Tward JD, Szabo A, Bentz BG, Shrieve DC. Relative contributions of radiation and cisplatin-based chemotherapy to sensorineural hearing loss in head-and-neck cancer patients. Int J Radiat Oncol Biol Phys. 2009;73(3):779–88.PubMedCrossRefGoogle Scholar
  48. 48.
    Wang SZ, Wang WF, Zhang HY, Guo M, Hoffman MR, Jiang JJ. Analysis of anatomical factors controlling the morbidity of radiation-induced otitis media with effusion. Radiother Oncol. 2007;85(3):463–8.PubMedCrossRefGoogle Scholar
  49. 49.
    Jereczek-Fossa BA, Zarowski A, Milani F, Orecchia R. Radiotherapy-induced ear toxicity. Cancer Treat Rev. 2003;29(5):417–30.PubMedCrossRefGoogle Scholar
  50. 50.
    Hsin CH, Chen TH, Young YH, Liu WS. Comparison of otologic complications between intensity-modulated and two-dimensional radiotherapies in nasopharyngeal carcinoma patients. Otolaryngol Head Neck Surg. 2010;143(5):662–8.PubMedPubMedCentralCrossRefGoogle Scholar
  51. 51.
    Murphy D, Daniel SJ. Intratympanic dexamethasone to prevent cisplatin ototoxicity: a guinea pig model. Otolaryngol Head Neck Surg. 2011;145(3):452–7.PubMedCrossRefGoogle Scholar
  52. 52.
    Adunka OF, Buchman CA. Cochlear implantation in the irradiated temporal bone. J Laryngol Otol. 2007;121(1):83–6.PubMedCrossRefGoogle Scholar
  53. 53.
    Pathak I, Bryce G. Temporal bone necrosis: diagnosis, classification, and management. Otolaryngol Head Neck Surg. 2000;123(3):252–7.PubMedCrossRefGoogle Scholar
  54. 54.
    Ramsden RT, Bulman CH, Lorigan BP. Osteoradionecrosis of the temporal bone. J Laryngol Otol. 1975;89(9):941–55.PubMedCrossRefGoogle Scholar
  55. 55.
    Lau WY, Chow CK. Radiation-induced petrous internal carotid artery aneurysm. Ann Otol Rhinol Laryngol. 2005;114(12):939–40.PubMedCrossRefGoogle Scholar
  56. 56.
    Ahmed S, Gupta N, Hamilton JD, Garden AS, Gidley PW, Ginsberg LE. CT findings in temporal bone osteoradionecrosis. J Comput Assist Tomogr. 2014;38(5):662–6.PubMedPubMedCentralCrossRefGoogle Scholar
  57. 57.
    Birzgalis AR, Ramsden RT, Farrington WT, Small M. Severe radionecrosis of the temporal bone. J Laryngol Otol. 1993;107(3):183–7.PubMedCrossRefGoogle Scholar
  58. 58.
    Xu YD, Ou YK, Zheng YQ, Zhang SY. Surgical treatment of osteoradionecrosis of the temporal bone in patients with nasopharyngeal carcinoma. J Laryngol Otol. 2008;122(11):1175–9.PubMedCrossRefGoogle Scholar
  59. 59.
    Zhou X, Ou X, Xu T, Wang X, Shen C, Ding J, et al. Effect of dosimetric factors on occurrence and volume of temporal lobe necrosis following intensity modulated radiation therapy for nasopharyngeal carcinoma: a case-control study. Int J Radiat Oncol Biol Phys. 2014;90(2):261–9.PubMedCrossRefGoogle Scholar
  60. 60.
    McDonald MW, Moore MG, Johnstone PA. Risk of carotid blowout after reirradiation of the head and neck: a systematic review. Int J Radiat Oncol Biol Phys. 2012;82(3):1083–9.PubMedCrossRefGoogle Scholar
  61. 61.
    Lambert EM, Garden AS, DeMonte F, Roberts DB, Gidley PW. Radiation-associated malignancies of the ear canal and temporal bone. Laryngoscope. 2015;125(5):1198–204.PubMedCrossRefGoogle Scholar
  62. 62.
    Frisch CD, Carlson ML, Link MJ. Synchronous head and neck tumors after low-dose radiation to the temporal bone. Otol Neurotol. 2012;33(1):e3–4.PubMedCrossRefGoogle Scholar
  63. 63.
    Patel SG, See AC, Williamson PA, Archer DJ, Rhys Evans PH. Radiation induced sarcoma of the head and neck. Head Neck. 1999;21(4):346–54.PubMedCrossRefGoogle Scholar
  64. 64.
    Shu M-T, Lin H-C, Lee J-C, Chen B-F. Radiation-induced squamous cell carcinoma of the external auditory canal. Otol Neurotol. 2011;32(3):e24–e5.PubMedPubMedCentralCrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Christopher D. Frisch
    • 1
  • Beth M. Beadle
    • 2
  • Paul W. Gidley
    • 3
    Email author
  1. 1.Department of OtolaryngologyOlmsted Medical CenterRochesterUSA
  2. 2.Department of Radiation OncologyStanford UniversityPalo AltoUSA
  3. 3.Department of Head and Neck SurgeryThe University of Texas M.D. Anderson Cancer CenterHoustonUSA

Personalised recommendations